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Article ; Online: Iron Deficiency Anemia in Pregnancy.

James, Andra H

2021 Volume 138, Issue 4, Page(s) 663–674

Abstract: Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester ( ...

Abstract	Anemia is defined as a low red blood cell count, a low hematocrit, or a low hemoglobin concentration. In pregnancy, a hemoglobin concentration of less than 11.0 g/dL in the first trimester and less than 10.5 or 11.0 g/dL in the second or third trimester (depending on the guideline used) is considered anemia. Anemia is the most common hematologic abnormality in pregnancy. Maternal anemia is associated with adverse fetal, neonatal and childhood outcomes, but causality is not established. Maternal anemia increases the likelihood of transfusion at delivery. Besides hemodilution, iron deficiency is the most common cause of anemia in pregnancy. The American College of Obstetricians and Gynecologists recommends screening for anemia with a complete blood count in the first trimester and again at 24 0/7 to 28 6/7 weeks of gestation. Mild anemia, with a hemoglobin of 10.0 g/dL or higher and a mildly low or normal mean corpuscular volume (MCV) is likely iron deficiency anemia. A trial of oral iron can be both diagnostic and therapeutic. Mild anemia with a very low MCV, macrocytic anemia, moderate anemia (hemoglobin 7.0-9.9 g/dL) or severe anemia (hemoglobin 4.0-6.9 g/dL) requires further investigation. Once a diagnosis of iron deficiency anemia is confirmed, first-line treatment is oral iron. New evidence suggests that intermittent dosing is as effective as daily or twice-daily dosing with fewer side effects. For patients with iron deficiency anemia who cannot tolerate, cannot absorb, or do not respond to oral iron, intravenous iron is preferred. With contemporary formulations, allergic reactions are rare.
MeSH term(s)	Administration, Oral ; Adult ; Anemia, Iron-Deficiency/diagnosis ; Anemia, Iron-Deficiency/drug therapy ; Blood Transfusion/statistics & numerical data ; Child ; Drug Administration Schedule ; Erythropoietin/metabolism ; Female ; Hemoglobins/analysis ; Humans ; Infant, Newborn ; Iron/administration & dosage ; Practice Guidelines as Topic ; Pregnancy ; Pregnancy Complications, Hematologic/diagnosis ; Pregnancy Complications, Hematologic/drug therapy ; Pregnancy Outcome ; Pregnancy Trimesters
Chemical Substances	Hemoglobins ; Erythropoietin (11096-26-7) ; Iron (E1UOL152H7)
Language	English
Publishing date	2021-10-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	207330-4
ISSN	1873-233X ; 0029-7844
ISSN (online)	1873-233X
ISSN	0029-7844
DOI	10.1097/AOG.0000000000004559
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Article ; Online: What do we know about why women bleed and what do we not know?

James, Andra H / James, Paula D

Journal of thrombosis and haemostasis : JTH

2023 Volume 22, Issue 2, Page(s) 315–322

Abstract: Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of ... ...

Abstract	Women or people with a uterus are vulnerable to both normal and abnormal bleeding. During the reproductive years, the uterus is prepared physiologically to accept an embryo and support its growth and development during pregnancy, or in the absence of implantation of an embryo, recycle through the process of menstruation and accept an embryo a month or so later. If fertilization takes place and an embryo or embryos implant in the uterus, the fetal trophoblast, or outer cell layer of the embryo, invades and dilates the maternal spiral arteries and forms the placenta. No matter when in gestation a pregnancy ends, at the conclusion of pregnancy, the placenta should separate from the wall of the uterus and be expelled. Abnormal bleeding occurs during pregnancy or after delivery when the normal uteroplacental interface has not been established or is interrupted; during miscarriage; during ectopic pregnancy; during premature separation of the placenta; or during postpartum hemorrhage. Heavy menstrual bleeding, a subset of abnormal menstrual bleeding, can be quantitatively defined as >80 mL of blood loss per cycle. Unlike postpartum hemorrhage, heavy menstrual bleeding is significantly associated with an underlying bleeding disorder. While there is other reproductive tract bleeding in women, notably bleeding at the time of ovulation or with a life-threatening ruptured ectopic pregnancy, the unique bleeding that women experience is predominantly uterine in origin. Many of the unique aspects of uterine hemostasis, however, remain unknown.
MeSH term(s)	Pregnancy ; Humans ; Female ; Postpartum Hemorrhage/diagnosis ; Postpartum Hemorrhage/therapy ; Menorrhagia ; Menstruation/physiology ; Pregnancy, Ectopic
Language	English
Publishing date	2023-09-13
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	2112661-6
ISSN	1538-7836 ; 1538-7933
ISSN (online)	1538-7836
ISSN	1538-7933
DOI	10.1016/j.jtha.2023.08.034
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Article ; Online: How I treat sickle cell disease in pregnancy.

James, Andra H / Strouse, John Joseph

Blood

2023 Volume 143, Issue 9, Page(s) 769–776

Abstract: Abstract: Fifty years ago, people with sickle cell disease (SCD) were discouraged from becoming pregnant, but now, most should be supported if they choose to pursue a pregnancy. They and their providers, however, should be aware of the physiological ... ...

Abstract	Abstract: Fifty years ago, people with sickle cell disease (SCD) were discouraged from becoming pregnant, but now, most should be supported if they choose to pursue a pregnancy. They and their providers, however, should be aware of the physiological changes of pregnancy that aggravate SCD and pregnancy's unique maternal and fetal challenges. Maternal problems can arise from chronic underlying organ dysfunction such as renal disease or pulmonary hypertension; from acute complications of SCD such as acute anemia, vaso-occlusive crises, and acute chest syndrome; and/or from pregnancy-related complications such as preeclampsia, sepsis, severe anemia, thromboembolism, and the need for cesarean delivery. Fetal problems include alloimmunization, opioid exposure, fetal growth restriction, preterm delivery, and stillbirth. Before and during pregnancy, in addition to the assessment and care that every pregnant patient should receive, patients with SCD should be evaluated and treated by a multidisciplinary team with respect to their unique maternal and fetal issues.
MeSH term(s)	Pregnancy ; Infant, Newborn ; Female ; Humans ; Anemia, Sickle Cell/complications ; Anemia, Sickle Cell/therapy ; Acute Chest Syndrome/etiology ; Pregnancy Complications/therapy ; Prenatal Care ; Pre-Eclampsia
Language	English
Publishing date	2023-11-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	80069-7
ISSN	1528-0020 ; 0006-4971
ISSN (online)	1528-0020
ISSN	0006-4971
DOI	10.1182/blood.2023020728
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Article ; Online: Case-based discussion on the implications of exogenous estrogens in hemostasis and thrombosis: the obstetrician's view.

James, Andra H

Hematology. American Society of Hematology. Education Program

2019 Volume 2019, Issue 1, Page(s) 148–151

Abstract: This is the obstetrician's view on 3 different clinical scenarios involving bleeding and thrombotic disorders. In the first scenario, an 18 year old with a history of heavy menstrual bleeding since menarche presents with abdominal pain and ultrasound ... ...

Abstract	This is the obstetrician's view on 3 different clinical scenarios involving bleeding and thrombotic disorders. In the first scenario, an 18 year old with a history of heavy menstrual bleeding since menarche presents with abdominal pain and ultrasound findings suggestive of a hemorrhagic ovarian cyst. The association with an underlying bleeding disorder is recognized. The goals of management, which are controlling hemorrhage and preserving fertility, are stated. Ovarian suppression, the most effective method to prevent recurrent hemorrhagic ovarian cysts, is outlined. Long-term management of heavy menstrual bleeding with hormonal contraception is described. In the second scenario, the same patient returns 5 years later for a preconception visit. The potential risks to an unborn baby with von Willebrand disease (VWD) are addressed. The natural rise in von Willebrand factor (VWF) during pregnancy is discussed, but the fact that women with VWD do not achieve the same VWF levels as women without VWD is emphasized and the implications are presented. In anticipation of pregnancy, the need for nonhormonal management of heavy menstrual bleeding and hemorrhagic ovarian cysts is mentioned. In the third and final scenario, the patient's cousin with factor V Leiden seeks consultation regarding the risks of thrombosis with in vitro fertilization. The steps of assisted reproductive technology are described. The strategies to prevent venous thromboembolism by preventing ovarian hyperstimulation and reducing the likelihood of multiple gestation are detailed.
MeSH term(s)	Adolescent ; Adult ; Estrogens/pharmacology ; Female ; Hemostasis/drug effects ; Humans ; Obstetrics ; Physicians ; Thrombosis/pathology
Chemical Substances	Estrogens
Language	English
Publishing date	2019-12-06
Publishing country	United States
Document type	Case Reports ; Journal Article
ZDB-ID	2084287-9
ISSN	1520-4383 ; 1520-4391
ISSN (online)	1520-4383
ISSN	1520-4391
DOI	10.1182/hematology.2019000071
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Article ; Online: Management of pregnant women who have bleeding disorders.

James, Andra H / Pacheco, Luis D / Konkle, Barbara A

Hematology. American Society of Hematology. Education Program

2023 Volume 2023, Issue 1, Page(s) 229–236

Abstract: Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management ... ...

Abstract	Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management of bleeding disorders in pregnant women requires not only an understanding of bleeding disorders but also an understanding of when and how bleeding occurs in pregnancy. Bleeding does not occur during a normal pregnancy with a healthy placenta. Bleeding occurs during pregnancy when there is an interruption of the normal utero-placental interface, during miscarriage, during an ectopic pregnancy, or at the time of placental separation at the conclusion of pregnancy. Although mild platelet defects may be more prevalent, the most commonly diagnosed bleeding disorder among women is VWD. Other bleeding disorders are less common, but hemophilia carriers are unique in that they are at risk of bleeding themselves and of giving birth to an affected male infant. General guidance for maternal management of a woman who is moderately or severely affected includes obtaining coagulation factor levels at a minimum in the third trimester; planning for delivery at a center with hemostasis expertise; and anticipating the need for hemostatic agents. General guidance for fetal management includes pre-pregnancy counseling; the option of preimplantation genetic testing for hemophilia; delivery at a tertiary care center with pediatric hematology and newborn intensive care; consideration of cesarean delivery of a potentially severely affected infant; and avoidance of invasive procedures such as scalp electrodes and operative vaginal delivery in any potentially affected infant.
MeSH term(s)	Child ; Infant, Newborn ; Female ; Pregnancy ; Male ; Humans ; Hemophilia A/diagnosis ; Hemophilia A/therapy ; Pregnant Women ; Placenta ; von Willebrand Diseases/diagnosis ; von Willebrand Diseases/therapy ; Hemorrhage/therapy ; Blood Coagulation Factors/therapeutic use
Chemical Substances	Blood Coagulation Factors
Language	English
Publishing date	2023-12-08
Publishing country	United States
Document type	Journal Article
ZDB-ID	2084287-9
ISSN	1520-4383 ; 1520-4391
ISSN (online)	1520-4383
ISSN	1520-4391
DOI	10.1182/hematology.2023000475
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Article ; Online: Von Willebrand Disease, Hemophilia, and Other Inherited Bleeding Disorders in Pregnancy.

Pacheco, Luis D / Saade, George R / James, Andra H

Obstetrics and gynecology

2023 Volume 141, Issue 3, Page(s) 493–504

Abstract: Inherited bleeding disorders, which comprise von Willebrand disease (VWD), hemophilia, other congenital clotting factor deficiencies, inherited platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal ... ...

Abstract	Inherited bleeding disorders, which comprise von Willebrand disease (VWD), hemophilia, other congenital clotting factor deficiencies, inherited platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Although mild platelet defects may actually be more prevalent, the most common diagnosed bleeding disorder among women is VWD. Other bleeding disorders, including hemophilia carriership, are much less common, but hemophilia carriers are unique in that they are at risk of giving birth to a severely affected male neonate. General guidance for maternal management of inherited bleeding disorders includes obtaining clotting factor levels in the third trimester, planning for delivery at a center with hemostasis expertise if factor levels do not meet the minimum threshold (eg, less than 0.50 international units/1 mL [50%] for von Willebrand factor, factor VIII, or factor IX), and using hemostatic agents such as factor concentrates, desmopressin, or tranexamic acid. General guidance for fetal management includes prepregnancy counseling, the option of preimplantation genetic testing for hemophilia, and consideration of delivery of potentially affected male neonates with hemophilia by cesarean delivery to reduce the risk of neonatal intracranial hemorrhage. In addition, delivery of possibly affected neonates should occur in a facility where there is newborn intensive care and pediatric hemostasis expertise. For patients with other inherited bleeding disorders, unless a severely affected neonate is anticipated, mode of delivery should be dictated by obstetric indications. Nonetheless, invasive procedures such as fetal scalp clip or operative vaginal delivery should be avoided, if possible, in any fetus potentially affected with a bleeding disorder.
MeSH term(s)	Infant, Newborn ; Pregnancy ; Female ; Humans ; Male ; Child ; von Willebrand Diseases/complications ; von Willebrand Diseases/diagnosis ; von Willebrand Diseases/genetics ; Hemophilia A/complications ; Hemophilia A/diagnosis ; Hemophilia A/genetics ; Hemorrhage/etiology ; Hemostatics ; Parturition ; von Willebrand Factor
Chemical Substances	Hemostatics ; von Willebrand Factor
Language	English
Publishing date	2023-02-02
Publishing country	United States
Document type	Journal Article
ZDB-ID	207330-4
ISSN	1873-233X ; 0029-7844
ISSN (online)	1873-233X
ISSN	0029-7844
DOI	10.1097/AOG.0000000000005083
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Article ; Online: Prevention and Management of Thromboembolism in Pregnancy When Heparins Are Not an Option.

James, Andra H

Clinical obstetrics and gynecology

2018 Volume 61, Issue 2, Page(s) 228–234

Abstract: Heparins, unfractionated heparin, and low molecular weight heparin, are the preferred anticoagulants in pregnancy. There are circumstances, however, in which an alternative to heparin should be considered. These circumstances include, the presence of ... ...

Abstract	Heparins, unfractionated heparin, and low molecular weight heparin, are the preferred anticoagulants in pregnancy. There are circumstances, however, in which an alternative to heparin should be considered. These circumstances include, the presence of heparin resistance, a heparin allergy manifesting as heparin-induced skin reactions or heparin-induced thrombocytopenia, and the presence of a mechanical heart valve. From time to time, the obstetrician is called on to make recommendations about anticoagulants in pregnancy, including in circumstances in which an alternative to heparin has been suggested or is necessary. In this article, these circumstances are reviewed and alternative anticoagulants are discussed.
MeSH term(s)	Anticoagulants/adverse effects ; Contraindications, Drug ; Drug Hypersensitivity/complications ; Drug Resistance ; Female ; Heart Valve Prosthesis ; Heparin/adverse effects ; Humans ; Pregnancy ; Pregnancy Complications, Hematologic/drug therapy ; Pregnancy Complications, Hematologic/prevention & control ; Thromboembolism/drug therapy ; Thromboembolism/prevention & control
Chemical Substances	Anticoagulants ; Heparin (9005-49-6)
Language	English
Publishing date	2018-03-07
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	391207-3
ISSN	1532-5520 ; 0009-9201
ISSN (online)	1532-5520
ISSN	0009-9201
DOI	10.1097/GRF.0000000000000357
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Article ; Online: Foreword: The Prevention and Management of Thrombosis in Obstetrics and Gynecology.

James, Andra H

Clinical obstetrics and gynecology

2018 Volume 61, Issue 2, Page(s) 203–205

MeSH term(s)	Blood Coagulation/physiology ; Female ; Humans ; Pregnancy ; Pregnancy Complications, Hematologic/therapy ; Risk Factors ; Thromboembolism/therapy ; Thrombosis/therapy
Language	English
Publishing date	2018-04-24
Publishing country	United States
Document type	Introductory Journal Article
ZDB-ID	391207-3
ISSN	1532-5520 ; 0009-9201
ISSN (online)	1532-5520
ISSN	0009-9201
DOI	10.1097/GRF.0000000000000373
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Article ; Online: Heavy menstrual bleeding: work-up and management.

James, Andra H

Hematology. American Society of Hematology. Education Program

2017 Volume 2016, Issue 1, Page(s) 236–242

Abstract: Heavy menstrual bleeding (HMB), which is the preferred term for menorrhagia, affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on anticoagulation. HMB can be predicted on the basis of clots of ≥1 inch diameter, low ferritin, ... ...

Abstract	Heavy menstrual bleeding (HMB), which is the preferred term for menorrhagia, affects ∼90% of women with an underlying bleeding disorder and ∼70% of women on anticoagulation. HMB can be predicted on the basis of clots of ≥1 inch diameter, low ferritin, and "flooding" (a change of pad or tampon more frequently than hourly). The goal of the work-up is to determine whether there is a uterine/endometrial cause, a disorder of ovulation, or a disorder of coagulation. HMB manifest by flooding and/or prolonged menses, or HMB accompanied by a personal or family history of bleeding is very suggestive of a bleeding disorder and should prompt a referral to a hematologist. The evaluation will include the patient's history, pelvic examination, and/or pelvic imaging, and a laboratory assessment for anemia, ovulatory dysfunction, underlying bleeding disorder, and in the case of the patient on anticoagulation, assessment for over anticoagulation. The goal of treatment is to reduce HMB. Not only will the treatment strategy depend on whether there is ovulatory dysfunction, uterine pathology, or an abnormality of coagulation, the treatment strategy will also depend on the age of the patient and her desire for immediate or long-term fertility. Hemostatic therapy for HMB may serve as an alternative to hormonal or surgical therapy, and may even be life-saving when used to correct an abnormality of coagulation.
MeSH term(s)	Adolescent ; Adult ; Anticoagulants/adverse effects ; Anticoagulants/therapeutic use ; Female ; Hemorrhage/blood ; Hemorrhage/chemically induced ; Hemorrhage/diagnosis ; Hemorrhage/therapy ; Humans ; Menstruation ; Middle Aged
Chemical Substances	Anticoagulants
Language	English
Publishing date	2017-01-13
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	2084287-9
ISSN	1520-4383 ; 1520-4391
ISSN (online)	1520-4383
ISSN	1520-4391
DOI	10.1182/asheducation-2016.1.236
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Article ; Online: Pregnancy, contraception and venous thromboembolism (deep vein thrombosis and pulmonary embolism).

James, Andra H

Vascular medicine (London, England)

2017 Volume 22, Issue 2, Page(s) 166–169

MeSH term(s)	Contraception ; Female ; Humans ; Pregnancy ; Pulmonary Embolism/diagnosis ; Pulmonary Embolism/surgery ; Risk ; Venous Thromboembolism/diagnosis ; Venous Thromboembolism/pathology ; Venous Thrombosis/diagnosis ; Venous Thrombosis/surgery
Language	English
Publishing date	2017-03-01
Publishing country	England
Document type	Journal Article ; Review
ZDB-ID	1311628-9
ISSN	1477-0377 ; 1358-863X
ISSN (online)	1477-0377
ISSN	1358-863X
DOI	10.1177/1358863X17690601
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